Comprehensive Medical Home Care

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on the review of agency policies/procedures and clinical records, and based on interview with the Administrator (Employee #12) and the Chief Executive Officer/Director of Clinical Services (CEO/DoCS-Employee #13), the agency failed to ensure wound care orders were consistent with skilled nursing (SN) interventions included on the comprehensive assessment for one (1) of two (2) patients for whom home health services were resumed after hospitalization. (Patient #4) Findings include: On February 5, 2026 at approximately 3:20 PM, review of agency policy 2-018, titled “Care Planning Process” revealed the following under “Procedure”: 8. The plan of care will be revised no less than every sixty (60) days or as frequently as deemed necessary by the clinician, based on the ongoing assessment of the patient. On February 5, 2026 at approximately 3:20 PM, review of agency policy 5-006, titled “Entries into the Clinical Record”, revealed the following: Policy...Documentation in the clinical record will be...accurate...The clinical record should tell a linear story of the course of the patient’s care that is managed and delivered by the organization. Patient #4 (Discharge): Between February 3, 2026 at approximately 10:32 AM and February 5, 2026 at approximately 1:07 PM, review of the clinical record revealed wound care provided by the SN (Employee #1) included the following as documented on the resumption of care (ROC) assessment dated 06/10/2025: -Right Lower Extremity Wounds (Wounds #1, #3, #8, #9): Aquacel Ag (wound treatment which contains silver) applied. Review ROC orders obtained by the SN (Employee #1) on 06/10/2025 revealed wound care orders included the following as documented on the “Post Hospital Order”: -RLE ulcer and non-pressure ulcer wound care orders included on page 2 and 3: Apply Aquacel Ag three (3) times a week -RLE ulcer wound care orders included on page 4: Apply Xeroform (wound dressing/treatment) twice a week -RLE non-pressure ulcer wound care orders included on page 4: Apply Xeroform every other day. -RLE non-pressure ulcer wound care orders included on page 5: Apply Xeroform and cover with Allevyn border (foam dressing) three (3) times a week and apply Xeroform three (3) times a week. There was no documentation on the “Post Hospital Order” dated 06/10/2025 which provided evidence wound care orders obtained by the SN for the application of Xeroform to the RLE ulcer and non-pressure ulcer wounds were consistent with the wound care provided by the SN during the resumption of care visit completed on 06/10/2025. During interview conducted on February 5, 2026 at approximately 3:25 PM, the Administrator and the CEO/DoCS confirmed wound care orders included on the “Post Hospital Order” were not consistent with SN wound care interventions completed during ROC visit for patient #4.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on the review of agency policies/procedures and clinical records, and based on interview with the Administrator (Employee #12) and the Chief Executive Officer/Director of Clinical Services (CEO/DoCS-Employee #13), the agency failed to ensure skilled nursing (SN) wound assessment findings were documented in accordance with agency policy/procedure and/or physician orders for three (3) of twelve (12) patients for whom wound care was provided by SN staff. (Patients #1, #2 and #15) Findings include: On February 5, 2026 at approximately 3:20 PM, review of agency policy 5-006, titled “Entries into the Clinical Record”, revealed the following: Policy...Documentation in the clinical record will be...accurate and reflect the care or services provided...The clinical record should tell a linear story of the course of the patient’s care that is managed and delivered by the organization. Procedure...1. A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies...and will include at a minimum: G. Current patient status and progress towards goals... On February 5, 2026 at approximately 2:59 PM, review of agency policy 2-014, titled “Wound Care Assessment”, revealed the following under “Procedure”: 2. Documentation of Assessment includes: a. Location and type... b. Length x width x depth... d. Tissue type/color e. Exudate (drainage)-Measurable amount... g. Periwound (tissue surrounding wound) condition... 6. Wound evaluation every visit... Patient #1 (Discharge): Between February 2, 2026 at approximately 12:39 PM and February 5, 2026 at approximately 1:00 PM, review of the clinical record revealed SN was to provide wound care to the left heel wound and that SN interventions included the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 11/25/2025 through 01/23/2026: SN to assess wound noting condition of wound bed, drainage and periwound and for SN to measure wound weekly. Review of SN visit note documentation dated 12/01/2025 revealed the SN (Employee #8) provided wound care to the left foot wound and that the SN documented that were no signs/symptoms of infection. There was no documentation on the SN visit noted dated 12/01/2025 which provided evidence the SN assessed the condition of the wound bed, wound drainage nor the periwound. Review of the verbal order dated 12/10/2025 revealed an order was received for SN to provide care to the right heel wound (new wound). Review of SN visit note documentation dated 12//10/2025 revealed the SN (Employee #1) provided wound care to the right heel wound. There was no documentation on the SN visit noted dated 12/10/2025 which provided evidence the SN assessed the right heel wound size nor the condition of the wound bed, wound drainage nor the periwound. Patient #2 (Discharge): Between February 2, 2026 at approximately 1:56 PM and February 5, 2026 at approximately 1:03 PM, review of the clinical record revealed SN was to provide wound care to the left lateral foot wound and that SN goals included the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 11/14/2025 through 01/12/2026: Wound will decrease in size and heal without complications. Review of SN visit note documentation dated 12/11/2025 revealed the SN (Employee #8) provided wound care to the left foot wound and that the SN documented that were no signs/symptoms of infection. There was no documentation on the SN visit noted dated 12/11/2025 which provided evidence the SN assessed the condition of the wound bed, wound drainage nor the periwound. Patient #15: On February 5, 2026 at approximately 7:40 AM, review of the clinical record revealed an additional SN visit was ordered to assess right lower leg and for ace wrap application as ordered on the physician order dated 01/23/2026. Review of the start of care assessment dated 01/17/2026 revealed there were no surgical, stasis ulcer nor pressure wounds present during the initial SN assessment. Review of SN visit note documentation dated 01/24/2026 revealed the SN (Employee #13) documented the knee was assessed and was without signs or symptoms of infection, that wound care was provided and that discharge planning included for “when knee is healed”. The SN documented an ace wrap was applied to the left leg. Review of SN visit note documentation dated 01/29/2026 revealed a right knee Incision present, that the incision was clean, dry, intact and closed with surgical glue, and that no signs/symptoms of infection were noted. There was no documentation on the SN visit noted dated 01/24/2026 which provided evidence the SN documented the location and type of knee wound which was assessed nor was documentation present which provided evidence the SN had assessed the length/width/depth of wound to which wound care was provided nor the status of wound drainage. During interview conducted on February 5, 2026 at approximately 3:25 PM, the Administrator and the CEO/DoCS confirmed wound assessment documentation was no completed in accordance with agency policies/procedures or physician orders on the aforementioned dates for the above identified patients.”